Acupuncture for Depression

Acupuncture for depression (Review)

Smith CA, Hay PPJ

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library2009, Issue 2

http://www.thecochranelibrary.com

Acupuncture for depression (Review)

Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

http://www.thecochranelibrary.com

T A B L E O F C O N T E N T S

1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

17DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Analysis 1.1. Comparison 1 Acupuncture versus medication, Outcome 1 Reduction in severity of depression. . . . 18

Analysis 1.2. Comparison 1 Acupuncture versus medication, Outcome 2 Improvement in depression. . . . . . . 20

Analysis 2.1. Comparison 2 Acupuncture versus wait list control, Outcome 1 Reduction in severity of depression. . 20

Analysis 2.2. Comparison 2 Acupuncture versus wait list control, Outcome 2 Improvement in depression. . . . . 21

Analysis 3.1. Comparison 3 Acupuncture versus non-specific acupuncture, Outcome 1 Reduction in severity of

depression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Analysis 3.2. Comparison 3 Acupuncture versus non-specific acupuncture, Outcome 2 Improvement in depression. . 22

Analysis 4.1. Comparison 4 Acupuncture plus medication versus medication, Outcome 1 Reduction in severity of

depression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Analysis 4.2. Comparison 4 Acupuncture plus medication versus medication, Outcome 2 Improvement in depression. 23

Analysis 5.1. Comparison 5 Acupuncture plus medication versus acupuncture plus placebo, Outcome 1 Reduction in

severity of depression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Analysis 5.2. Comparison 5 Acupuncture plus medication versus acupuncture plus placebo, Outcome 2 Improvement in

depression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

24WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

24HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

24CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

24DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

iAcupuncture for depression (Review)


[Intervention Review]

Acupuncture for depression

Caroline A Smith1, Phillipa PJ Hay2

1Centre for Complementary Medicine Research, The University of Western Sydney, Penrith South DC, Australia. 2Mental Health

School of Medicine , Building 3 , Penrith South, Australia

Contact address: Caroline A Smith, Centre for Complementary Medicine Research, The University of Western Sydney, Locked Bag

1797, Penrith South DC, New South Wales, 1797, Australia. [email protected]. (Editorial group: Cochrane Depression,

Anxiety and Neurosis Group.)

Cochrane Database of Systematic Reviews, Issue 2, 2009 (Status in this issue: Unchanged)


DOI: 10.1002/14651858.CD004046.pub2

This version first published online: 19 July 2004 in Issue 3, 2004.

Last assessed as up-to-date: 16 March 2004. (Help document - Dates and Statuses explained)

This record should be cited as: Smith CA, Hay PPJ. Acupuncture for depression. Cochrane Database of Systematic Reviews 2004,

Issue 3. Art. No.: CD004046. DOI: 10.1002/14651858.CD004046.pub2.

A B S T R A C T

Background

There is interest from the community in the use of self help and complementary therapies for depression. This review examined the

currently available evidence supporting the use of acupuncture to treat depression.

Objectives

To examine the efficacy and adverse effects of acupuncture for depression.

Search strategy

The following databases were searched: Cochrane Central Register of Controlled Trials (CENTRAL) MEDLINE (1966 to Sept 2003)

EMBASE (1980 to Sept 2003) PSYCINFO (1874 to Sept 2003) the Database of Abstracts of Reviews of Effectiveness (DARE)

CISCOM, CINAHL (January 1980 to Sept 2003). The following terms were used: depression, depressive disorder, dysthymic disorder

and acupuncture.

Selection criteria

Inclusion criteria included all published and unpublished randomised controlled trials comparing acupuncture with sham acupuncture,

no treatment, pharmacological treatment, other structured psychotherapies (cognitive behavioural therapy, psychotherapy or coun-

selling), or standard care. The following modes of treatment were included: acupuncture, electro acupuncture or laser acupuncture.

The subjects included adult men and women with depression defined by clinical state description, or diagnosed by the Diagnostic and

Statistical Manual (DSM-IV), Research Diagnostic Criteria (RDC), or the International Classification of Disease (ICD).

Data collection and analysis

Meta analysis was performed using relative risk for dichotomous outcomes and weighted mean differences for continuous outcomes,

with 95% confidence intervals. Primary outcomes were reduction in the severity of depression, measured by self rating scales, or by

clinician rated scales; and an improvement in depression defined as remission vs no remission.

Main results

Seven trials comprising 517 subjects met the inclusion criteria. Five trials (409 subjects) included a comparison between acupuncture

and medication. Two other trials compared acupuncture with a wait list control or sham acupuncture. Subjects generally had mild

1Acupuncture for depression (Review)


mailto:[email protected]

http://www3.interscience.wiley.com/cgi-bin/mrwhome/106568753/DatesStatuses.pdf

to moderate depression. There was no evidence that medication was better than acupuncture in reducing the severity of depression

(WMD 0.53, 95%CI -1.42 to 2.47), or in improving depression, defined as remission versus no remission (RR1.2, 95%CI 0.94 to

1.51).

Authors’ conclusions

There is insufficient evidence to determine the efficacy of acupuncture compared to medication, or to wait list control or sham

acupuncture, in the management of depression. Scientific study design was poor and the number of people studied was small.

P L A I N L A N G U A G E S U M M A R Y

Acupuncture for depression

In clinical depression people often report a lack of interest in life and normally enjoyed activities, accompanied by other symptoms

including weight loss/over-eating, feelings of uselessness, sleep disturbance, self neglect and social withdrawal, insomnia/hypersomnia,

loss of energy, low self esteem and poor concentration. Depression is widely experienced in our communities. There are studies indicating

a preference for treatment with self-help and complementary therapies for depression. This review examined the efficacy and adverse

effects of acupuncture in treating depression. Based on the findings from seven trials of low quality, there is insufficient evidence to

determine whether acupuncture is effective in the management of depression.

B A C K G R O U N D

Clinical depression is a syndrome characterised by a number of

behavioural, cognitive and emotional features. Depressed patients

often exhibit signs of dysphoric mood, loss of interest in normally

enjoyable things, self neglect and social withdrawal, poor appetite

or overeating, insomnia or hypersomnia, fatigue or loss of energy,

low self esteem, poor concentration or difficulty making decisions,

and feelings of hopelessness.

Depression is recognised as a major public health problem, which

has a substantial impact on individuals and to society. Depres-

sive disorders are common in the general population. In Aus-

tralia, 5.8% of Australian adults experience a depressive disorder

(Andrews 1999). The rate of depression among women is two to

three times that of men (Myer 1984). The World Health Organ-

isation has described depression as an “unseen burden” (Murray

1996). The Global Burden of Disease study reported that when

measured by Disability Adjusted Life Years (DALY), unipolar ma-

jor depression ranked fourth in 1990, and would rise to second by

2020, in terms of the overall burden of all diseases in the world. In

terms of disability alone, defined as a restriction or lack of ability

to perform an activity in the manner or range considered normal

(WHO 1980), unipolar depression ranked first in 1990, affecting

51 million people and contributing 10.7% of the total years lived

with disability from all causes (Murray 1996). It has been demon-

strated in the community that those who suffer depressive disor-

ders experience reduced physical and mental functioning, similar

to patients with chronic diseases such as diabetes (Hays 1995 and

Wells 1989). Mood disorders have, in addition, been shown to

have a greater impact on quality of life compared with conditions

such as hypertension and cardiac disease (Spitzer 1995).

The majority of depressed patients are managed in primary care

and do not require hospitalisation. This illness has considerable

financial costs to health services and to society. The cost of de-

pression in the United States has been estimated at $43 billion per

year (Greenberg 1993).

In primary care depression is most frequently treated with an-

tidepressants (Goldman 1999). In addition, there are a range of

psychological interventions, including cognitive behaviour thera-

pies, interpersonal therapy, psychotherapy and counselling. Sur-

veys in Australia have shown that Australians report a preference

for self-help and complementary therapies for depression (Jorm

1997, Jorm 2000). In an Australian survey, it has been estimated

that 49% of adults have used some form of complementary ther-

apy, and a fifth have consulted a complementary practitioner (

MacLennan 1996). In the United States, results from a survey in-

dicate that people who are depressed have a higher use of comple-

mentary therapies (Kessler 2000).

Acupuncture has a long history of use in China and Japan. Tradi-

tional Chinese medicine theory describes a state of health main-

tained by a balance of energy in the body. Acupuncture involves

the insertion of fine needles into different parts of the body to

correct the imbalance of energy in the body. There are a range of

styles of acupuncture from traditional/classical acupuncture, au-

ricular acupuncture, trigger point acupuncture, and single point

acupuncture. Traditional Chinese Medicine (TCM) and Classical



Acupuncture is based on the Chinese philosophical ideas of Yin

and Yang and the Five Elements which form the basis of Chinese

medical theory. These theories form the basis for explaining dis-

ease and physiological function. A westernised medical application

of acupuncture involves the use of acupuncture administered in

relation to mainstream, and using trigger points, segmental points

and commonly used formula points. Medical acupuncture may

involve the application of acupuncture based on the principles of

neurophysiology and anatomy, and the exclusion of TCM princi-

ples and philosophy. Auricular therapy involves the use of the ear

to make a diagnosis and subsequent needling to points on the ear.

Conventional science suggests acupuncture works by neurologi-

cal, neurohormonal and psychological mechanisms. In relation to

depression, there is some evidence from animal experiments sug-

gesting acupuncture or electroacupuncture (EA) is capable of ac-

celerating the synthesis and release of serotonin (5-HT) and nore-

pinephrine (NE) in the central nervous system (Han 1986).

The rationale of treatment will determine the needling details (for

example selection or points, number of needles used) or method

of stimulation (for example use of electro-acupuncture (involves

passing a pulsed current through body tissues via acupuncture

needles), laser acupuncture (the use of low power laser to stimulate

the acupuncture point) and acupressure (the application of finger

pressure). It is possible that these different styles of acupuncture

may differ in their effectiveness, although there is little research

examining this question. Similarly, the design of the acupuncture

control in acupuncture research can range from invasive to non-

invasive procedures and wait list controls, and the design may

influence the placebo or non specific needling effects arising from

the control group design.

Acupuncture is not entirely free of adverse side effects. In a sur-

vey of acupuncture practitioners in Australia, minor reactions to

acupuncture treatment such as nausea and vomiting, fainting and

increased pain were reported (Bensoussan 2000). Acupuncture

practitioners experienced an average of one adverse effect reported

every eight to nine months of practice, or one adverse event for

every 633 consultations. It has been concluded that acupuncture

is a safe intervention in the hands of a competent practitioner (

Vincent 2001).

This review has examined the currently available evidence assessing

the efficacy and adverse effects of acupuncture for the treatment

of depression.

O B J E C T I V E S

To examine the efficacy and adverse effects of acupuncture for

depression.

1. To determine whether acupuncture is more effective than sham

acupuncture and no treatment with treating depression and im-

proving quality of life

2. To assess the efficacy of acupuncture versus standard treatment

(defined as medication, psychological intervention) with treating

depression and improving quality of life.

3. To determine the adverse effects of acupuncture compared with

sham acupuncture, no treatment and standard treatment (defined

as medication, psychological intervention) with the treatment of

depression.

M E T H O D S

Criteria for considering studies for this review

Types of studies

All published and unpublished randomised controlled trials com-

paring acupuncture with placebo (control acupuncture), no treat-

ment, pharmacological treatment, other structured psychothera-

pies (cognitive behavioural therapy, psychotherapy or counselling),

or standard care.

Types of participants

Adults with depression defined by clinical state description, or

diagnosed by the Diagnostic and Statistical Manual (DSM-IV,

APA 1994), or the Research Diagnostic Criteria (RDC, Spitzer

1977), or the International Classification of Disease (ICD, WHO

1993).

Types of interventions

Active group: classical acupuncture, electro acupuncture, laser

acupuncture versus

Control group: placebo-control (sham interventions, minimal

acupuncture, non-invasive control, electro-acupuncture), no treat-

ment (waiting list, treatment as usual), or pharmacological treat-

ment (standard medication to treat depression) or structured psy-

chotherapies (cognitive behavioural therapy, psychotherapy, coun-

selling) or other standard care as defined by the country-specific

health care setting.

Types of outcome measures

For inclusion data on at least one primary outcome needed to be

included.

Primary outcomes:

Reduction in the severity of depression, measured by self-rating

scales such as the Beck Depression Inventory (Beck 1961), or

by clinician-rated scales, such as the Hamilton Rating Scale for

Depression (Hamilton 1960).

Improvement in depression measured as a dichotomous outcome,

remission vs no remission. The authors recognise that subjective



assessment may give rise to a source of bias. If a difference was

found in this outcome, greater reliance was given to the validated

scales.

Secondary outcomes:

Quality of life indices (such as the Short Form 36 Health Status

questionnaire (Ware 1994))

Change in use of medication or use of other support systems

Adverse side effects

Acceptability of acupuncture, electro acupuncture or laser

acupuncture (assessed by questioning participants in the trial, or

satisfaction measures).

Short-term outcomes reported at the end of the trial intervention

as well as long-term outcomes were pooled where available.

Search methods for identification of studies

See: Collaborative Review Group search strategy.

Electronic Searches:The Cochrane Depression, Anxiety & Neuro-

sis Review Group Register (CCDANCTR-Studies) was searched

using the following terms: Diagnosis = Depressi* or Dysthymi*

and Intervention = Acupuncture

The following databases were searched using the following items:

depression, depressive disorder, dysthymic disorder and acupunc-

ture. Cochrane Central Register of Controlled Trials (CEN-

TRAL) MEDLINE (1966 to September 2003) EMBASE (1980

to September 2003) PSYCINFO (1874 to September 2003) the

Database of Abstracts of Reviews of Effectiveness (DARE) CIS-

COM (database of the Research Council for Complementary

Medicine), CINAHL (January 1980 to September 2003). Assis-

tance was sought from the Chinese Cochrane Centre to search

Chinese databases.

The reference lists of selected journals were inspected for more

published reports and for citations of unpublished randomised

controlled trials.

Data collection and analysis

Study selection

Translation of relevant Chinese language papers was made. Ab-

stracts of trials were evaluated for their appropriateness for inclu-

sion based on trial design and meeting the criteria of the type of

intervention by CS and PH. Where there was uncertainty about

inclusion of the study, the full text was retrieved. The original au-

thor was contacted for further information if necessary. Reasons

for excluding trials have been stated.

Data extraction

Following an assessment for inclusion, the methodology of the

trial was assessed. Data were extracted on patients, methods, in-

terventions, outcomes and results. The data were extracted onto

hard copy data sheets. Data extraction and quality assessment was

made by CS and PH. Missing data or clarification on the study

were sought from the respective authors.

Quality assessment

The methodological quality of the trials was assessed using the

criteria in the Cochrane Handbook describing the relationship

between allocation concealment and bias. Criteria for assessing

bias are described as:

A Low risk of bias (adequate allocation concealment)

B Moderate risk of bias (some doubt about results)

C High risk of bias (inadequate allocation concealment) (Clarke

2000).

A was used to indicate a trial which had a high level of quality in

which all the criteria were met;

B was used to indicate that one or more criteria were partially met

or if it was unclear if all the criteria were met, and

C was used if one or more criteria were not met (Clarke 2000).

Trials were included if they met the criteria A, B or C.

Included trials were assessed according to the following five main

criteria:

(1) adequate concealment of treatment allocation (e.g. opaque

sealed numbered envelopes);

(2) method of allocation to treatment (e.g. by computer randomi-

sation, random number tables);

(3) adequate documentation of how exclusions were handled after

treatment allocation - to facilitate intention to treat analysis;

(4) adequate blinding of outcome assessment, and

(5) losses to follow-up (trials with losses greater than 25%)

Data analysis

Data were entered directly from the data sheets into the Review

Manager software (Revman 2002) with double data entry per-

formed by PH. Where data were not presented in a suitable format

for data entry, or if data were missing, additional information was

sought from the trialists by personal communication in the form

of a letter or telephone call.

An intention to treat analysis enhances the quality of the trial,

and efforts were made to obtain additional data from the authors.

Statistical analysis was performed using the Review Manager (

Revman 2002) software. For dichotomous data, relative risks and

95% confidence intervals (CIs), were calculated. Weighted mean

difference (WMD) and 95% CIs for continuous data were calcu-

lated.

We tested for statistical heterogeneity between trials using a stan-

dard chi squared test. In the presence of significant heterogeneity,

a random effects meta-analysis was used. Causes of heterogeneity

were examined by pre specified subgroup analysis and sensitivity

analysis. The sensitivity analysis aimed to explore the influence of

high quality trials defined by random allocation (defined as ’A’)

versus moderate quality trials (defined as ’B’) and high quality

trials (defined as ’A’) versus low quality trials (defined as ’C’), if

sufficient trials were included.

Pre-specified subgroup analysis examined the effects of different

styles of acupuncture (for example classical/traditional acupunc-



ture versus single point therapy, or auricular acupuncture). Other

subgroup analyses planned to explore the effects of treatment in

people with different diagnoses (for example, major depression

and dysthymia), and in people of different ages (less <65 years and

> 65 years). Data were not reported to allow these other sub-group

analyses.

R E S U L T S

Description of studies

See: Characteristics of included studies; Characteristics of excluded

studies; Characteristics of ongoing studies.

A total of nine randomised controlled trials were identified. Seven

trials met the inclusion criteria, and two trials were excluded. The

Agelink 2003 trial was excluded because data describing cardio-

vascular outcomes only were reported. The Chang-du 1994 trial

was excluded because included subjects had experienced a stroke

(DSM IV criteria specify the exclusion of symptoms clearly due

to a medical condition).

Allen 1998

Thirty-four women in the United States with clinical depression

were recruited to this trial. Women were randomised into three

groups; acupuncture designed to treat depression (n=14), a non-

specific acupuncture group (n=12) which involved acupuncture to

treat a pattern of disharmony unrelated to depression, and a wait

list control (n=12). The intervention was carried out over eight

weeks, and was followed by women in the non-specific acupunc-

ture and wait list control group receiving acupuncture for eight

weeks. Acupuncture was administered by four trained and board

certified acupuncturists. No details were reported on the acupunc-

ture points used. Women were treated twice a week for the first

four weeks, followed by once weekly sessions for four weeks. Base-

line characteristics were presented on the subjects. Four women

(11%) dropped out from the study. An intention to treat analysis

was not performed.

Han 1986

Sixty-six men and women aged 18-55 years were recruited to this

trial from the Beijing University Mental Health Institute, China.

Inclusion criteria were ICD-10 and a score of greater than 20 on

the Hamilton Depression Rating Scale. Subjects were randomised

to receive electro-acupuncture (n=30) or maprotiline (n=31). Elec-

tro-acupuncture was administered for 45 minutes, six times a

week, over six weeks. A variety of acupuncture points were used

in the trial to treat Heart, Liver and Kidney deficiency. The nee-

dle depth was described, and electro-stimulation was given for 45

minutes. De qi (needling sensation) was obtained. The medicated

group received daily medication, with doses ranging from 75-250

mg, for six weeks. Subjects completed the Hamilton Depression

Rating Scale. Baseline characteristics were not presented by study

group. Five subjects (8%) did not complete the trial.

Luo 1985

Forty-seven men and women were recruited to this trial, un-

dertaken in China. Subjects were randomised to receive electro-

acupuncture (n=27) or amitriptyline (n=20). Two acupuncture

points were stimulated, Baihui and Yintang. Needles were stimu-

lated using electro-acupuncture for 60 minutes. Subjects received

six sessions a week for five weeks. Needles were inserted to a depth

of eight fen. Electro-stimulation was given until a twitch was vis-

ible. The frequency of stimulation was 80-90 beats per minute.

Subjects taking their medication received an average dose of 142

mg per day. There was no loss to follow up reported.

Luo 1988

Two hundred and forty one men and women were recruited

from 10 psychiatric hospitals in China. Subjects were randomised

to receive electro-acupuncture plus placebo tablets (n=133) or

amitriptyline (n=108). Two acupuncture points were stimulated,

Baihui and Yintang. Needles were stimulated using electro-

acupuncture for 45 minutes. The current was 3-5mA at a fre-

quency of 2Hz. Subjects received six sessions a week for six weeks.

Subjects taking their medication received an initial dose of 25 mg

three times a day, which was increased to 150mg three times a day.

Subjects completed the Hamilton Depression Rating Scale. There

was no loss to follow up reported.

Luo 1998

Twenty nine men and women were recruited from the Bei-

jing Medical University in China. Subjects were randomised to

one of three groups to receive electro-acupuncture plus placebo

tablets (n=8), or amitriptyline (n=11), or electro-acupuncture

and amitriptyline (n=10). Two acupuncture points were stimu-

lated, Baihui and Yintang. Needles were stimulated using electro-

acupuncture for 45 minutes, the current was 3-5mA at a frequency

of 2Hz. Subjects received six sessions a week for six weeks. Needles

were inserted to a depth of 2-3 cm. A twitch sensation was ob-

tained. The treatment session took 45 minutes, although the time

of retention was not specified. Treatments were administered six

days, for six weeks. No other co-interventions were administered.

No details on the practitioner background were reported. The only

information presented on the dosage for the amitriptyline group

was that the dose averaged 175mg per day. For those in the com-

bined treatment group, a dose of 150mg per day was reported.

Subjects completed the Hamilton Depression Rating Scale. There

was no loss to follow up reported.

Roschke 2000

Seventy German men and women, aged 20-70 years, with a clini-

cal diagnosis of depression were randomised to mianserin (90-120

mg/day) (n=24), mianserin (90-120 mg/day) plus verum acupunc-

ture (n=22), manserin (90-120 mg/day) plus placebo acupunc-

ture(n=24). Manual acupuncture was applied three times a week

over four weeks, and administered by two clinicians experienced

in traditional Chinese medicine. The duration of treatment was



30 minutes. Acupuncture was administered bi-laterally at points

Bladder 15, Bladder 17, Bladder 18, Heart 7, Pericardium 6, Stom-

ach 40, Spleen 5, Spleen 6, and Lung 1. Electrical resistance was

used to determine point location. Needles were inserted to a depth

of a few millimetres and needles removed after a few minutes.

Acupuncture was performed by two experienced acupuncturists.

No further details were provided. The treatment used a standard-

ised whole body acupuncture treatment applied three times a day,

over four weeks, with each treatment lasting 30 minutes. For the

placebo group, needles were inserted at non-acupuncture points.

To measure depression the Global Assessment Scale, Melancho-

lia scale, and Clinical Global Impressions Scale were used. Mean

self reported and dosage of medication were calculated. Baseline

characteristics were presented on the participants. There were no

losses to follow up.

Xiujuan 1994

Forty one men and women were recruited from in-patient and

out-patient care at a University Hospital in China. Subjects were

randomised to receive acupuncture (n=20) or standard medical

care using amitriptyline (n=21). Acupuncture points Governor

vessel 24, Governor vessel 20, Governor vessel 14, Governor ves-

sel 12, Conception vessel 17, Conception vessel 14, Gall bladder

20, Pericardium 6 were used. Additional acupuncture points were

used depending on the Chinese medical diagnosis. For stagnation

of Liver qi Stomach 23, Spleen 6 and Liver 3 were used. For stag-

nation of Liver blood Colon 4, Liver 3, Spleen 10 were used. For

Spleen and Heart deficiency Heart 7, Pericardium 7, Spleen 6 and

Stomach 36 were used. For Spleen and Kidney yang deficiency

Kidney 3, Spleen 6, Stomach 36 and Conception vessel 4 were

used. Needles were inserted bi-laterally, and stimulated manually,

except for Governor vessel 24 and Governor vessel 20, which were

stimulated using electro acupuncture (frequency 80-100/second).

Treatment was administered six days a week over six weeks. The

control group took 25 mg of amitriptyline on the first day, and

the dose was increased by 25-50 mg each day up to 150 mg. In the

second week the dose was adjusted according to response and side

effects, but ranged from 150 mg to 300 mg daily. The Hamilton

Rating Scale for Depression was used to collect data once a week

over six weeks. Data were also available on patients cured. No data

were presented on baseline characteristics. There were no losses to

follow up.

Risk of bias in included studies

ALLOCATION CONCEALMENT

The Allen 1998 trial was given a score of A. Han 1986, Luo 1985,

Luo 1988, Luo 1998, Roschke 2000 and Xiujuan 1994 trials were

given a score of B, as the allocation concealment was unclear.

METHOD OF CONCEALMENT

Central randomisation was undertaken in the Allen 1998 trial.

The method of allocation was not reported for the Han 1986,

Luo 1985, Luo 1988, Luo 1998, Roschke 2000 and Xiujuan 1994

trials.

BLINDING

In the Allen 1998 trial the patient, therapist (valid acupuncture

points were used but the therapists were blind to the experimental

hypotheses) and outcome assessor were blind. It was unclear if the

analyst was blind.

In the Roschke 2000 trial, it was unclear if subjects were blind

to their acupuncture group; although the authors reported that

subjects were blind to their acupuncture group allocation, this

was not verified with data. It was not feasible for the acupuncture

therapist to be blind. The outcome analyst was reported to be

blind in the trial, but it was unclear if the analyst was blind in the

Roschke 2000 trial.

In the Luo 1985, Han 1986 and Xiujuan 1994 trials, trial subjects

and the therapist were not blind. It was unclear if the outcome

assessor and analyst were blind to study group allocation.

In the Luo 1988 and Luo 1998 trials, full details on who was blind

was not reported.

INTENTION TO TREAT ANALYSIS

An intention to treat analysis was mentioned and performed in

the Roschke 2000, Xiujuan 1994 and Luo 1985, Luo 1988 and

Luo 1998 trials. An intention to treat analysis was not undertaken

in the Allen 1998 and Han 1986 trials.

LOSSES TO FOLLOW UP

There were no losses reported in the Roschke 2000, Luo 1985,

Luo 1988, Luo 1998 and Xiujuan 1994 trials. In the Allen 1998

trial, four women (11%) dropped out and one was included in

the analysis. Reasons for dropout included pregnancy, moving in-

terstate, discomfort with the treatment. One woman dropped out

because she did not lose weight, which she believed she would do

from receiving pharmacological treatment. In the Han 1986 trial,

five subjects (8%) were lost to follow up.

Effects of interventions

An overall seven trials were included in the meta analysis. The

trials contained a total of 517 subjects.

ACUPUNCTURE VERSUS MEDICATION

Reduction in severity of depression

Five studies (409 participants) reported on a reduction in the sever-

ity of depression using the Hamilton depression rating scale (Han

1986, Luo 1985, Luo 1988, Luo 1998 and Xiujuan 1994). Overall

there was no significant difference between groups (WMD 0.53

95%CI -1.42 to 2.47). Borderline heterogeneity was identified

in the meta-analysis and was explored through pre-specified sub-

group analysis by style of acupuncture. A comparison was made

between electro-acupuncture (Luo 1985, Luo 1988 and Luo 1998)

and a classical acupuncture approach (Han 1986 and Xiujuan

1994). In the meta-analysis of style of acupuncture, no difference



was found between groups of electro-acupuncture (WMD -0.36,

95%CI -3.19 to 2.46), similarly no significant difference in the

severity of depression was found in the two trials using classical

acupuncture. The style of acupuncture did not explain the hetero-

geneity.

Improvement in depression

Four studies (375 participants) reported on this outcome and were

included in the meta-analysis (RR 1.20, 95 % CI 0.94 to 1.51).

No differences were found between groups in any of the four trials

(Luo 1985 RR 1.48, 95% CI 0.67 to 3.27; Luo 1988 RR 1.17,

95% CI 0.9 to 1.51; Xiujuan 1994 RR 0.88, 95% CI 0.32 to

2.42; and Roschke 2000 RR 4.36, 95% CI 0.53 to 36.12).

Adverse effects

Limited data were reported on adverse effects. Han 1986 re-

ported on adverse effects for the acupuncture group only. Sleep

disturbances were reported by 10% of subjects, headaches by 7%

and tiredness by 7% of subjects. Adverse effects relating to dry

mouth, constipation, heartburn, sleepiness and headaches were

reported by the medicated group, although data were not pre-

sented. Luo 1988 reported that adverse effects in the amitriptyline

group were significantly greater than in the acupuncture group.

Luo 1998 reported 138 adverse events in the acupuncture group,

with headaches (n=26), palpitations (n=16) and dryness of the

mouth (n=16) the most common adverse effects. In the medicated

group, 342 subjects reported slight adverse effects, with palpita-

tions (n=43), dryness of the mouth (n=42), and physical tiredness

(n=38) most commonly reported.

No other outcome measures were reported.

ACUPUNCTURE VERSUS WAIT LIST CONTROL

One study reported two outcomes for this comparison (Allen

1998).


Allen 1998 reported on the mean change in Hamilton Depression

Rating scores from baseline to eight weeks. No significant differ-

ence was found between groups (WMD -5.60, 95% CI -13.25 to

2.05).


Allen 1998 included 23 participants. In this study improvement

was defined as full remission. The outcome assessor was blind

in data collection. No significant difference between groups was

found (RR 2.29, 95% CI 0.55 to 9.49).

ACUPUNCTURE VERSUS NON SPECIFIC ACUPUNC-

TURE

A comparison was made in the Allen 1998 trial between the

acupuncture specific group to treat depression and a non-specific

acupuncture treatment group. Two outcomes were reported.


A greater mean reduction in depression scores was found among

participants in the acupuncture specific group compared with the

non-specific acupuncture group (WMD -8.80, 95% CI -15.03 to

2.57).


No significant difference was found in the numbers reporting full

remission between groups (RR.4.58, 95% CI 0.63 to 33.36).

ACUPUNCTURE PLUS MEDICATION VERSUS MEDICA-

TION

Two studies undertook this comparison (Roschke 2000 and Luo

1998). Two outcomes were reported.


In the study of 21 subjects receiving acupuncture in addition to

medication (Luo 1998), the subjects receiving medication alone

reported a greater reduction in the severity of depression (WMD

3.1, 95% CI 1.04 to 5.16).


One study (Roschke 2000) of 46 subjects found no significant

difference between these two groups (RR 4.36, 95% CI 0.53 to

36.12).

ACUPUNCTURE PLUS MEDICATION VERSUS

ACUPUNCTURE PLUS PLACEBO

Two studies undertook this comparison (Roschke 2000 and Luo

1998). Two outcomes were reported.


In the Luo 1998 trial of 28 subjects, no significant difference was

found in the severity of depression (WMD 1.4, 95% CI -0.92 to

3.72).


In the Roschke 2000 trial of 46 subjects, no significant difference

was found between the two groups for an improvement in depres-

sion (RR 0.55, 95% CI 0.19 to 1.56).

A sensitivity analysis based on the allocation criteria was not per-

formed, because only one trial (Allen 1998) met the criteria of

“A”.

D I S C U S S I O N

There is a lack of well designed randomised controlled trials to eval-

uate the role of acupuncture in treating depression. Acupuncture

has not been subjected to rigorous scientific study, and overall the

number of people studied was small. The results should therefore

be interpreted with caution. The majority of studies were of poor

methodological quality or inadequately reported. Internal validity

was poor in relation to selection of participants. For many studies

the lack of blinding in relation to outcome assessors and analyst

may have introduced a source of bias, as well as the subjective

bias from poorly defined criteria for the outcome “improvement

in depression”. The varying doses of medication reported in the

Luo trials suggest that the doses may not have been therapeutically

effective, or that the timing of assessment was too early.

Seven trials involving 517 participants were included in the meta-

analysis. The first comparison of acupuncture and medication in-

volved six trials, and included two outcomes. Five trials involv-



ing 409 participants were included in the first meta-analysis of

acupuncture and medication, and found no difference between

acupuncture and medication for reduction in severity of depres-

sion. However, the methodological quality of these five trials was

not high, details of randomisation were unclear, no power anal-

yses were reported and details of the acupuncture were not fully

reported. The style of acupuncture was explored in pre-specified

sub-group analyses. This variable did not explain the borderline

heterogeneity found. None of the trials included in this compari-

son were designed specifically to test equivalence. Due to the small

number of trials, the conclusions from the subgroup analysis and

sensitivity analysis were limited. Four trials involving 375 partic-

ipants were included in the second meta-analysis of acupuncture

and medication, and found no difference in improvement in de-

pression. The methodological quality of these four trials was low.

Though each of the four trials undertook an intention to treat anal-

ysis, and there were no losses to follow-up, they did not report on

the method of randomisation concealment and allocation, and in-

complete reporting on blinding suggests that the potential for bias

exists. The quality and available evidence from these randomised

controlled trials suggests that there is insufficient evidence relating

to the efficacy of acupuncture in relation to medication.

There was insufficient evidence to determine whether acupunc-

ture is more effective than a wait list control, non-specific or sham

acupuncture control, or whether acupuncture plus medication is

more effective than acupuncture plus placebo, because these com-

parisons involved only single studies and small numbers.

There are many styles of acupuncture, including traditional Chi-

nese medicine as used by Allen, and those using formula acupunc-

ture points as in the Luo trials. As illustrated in this review, there

is also wide variation in the mode of stimulation, duration of

needling, number of points used, depth of needling and needle

stimulation and duration of the trial. It is important for any future

trials of acupuncture to treat depression to report the basis for the

acupuncture treatment and needling as described in the STRICTA

guideline (MacPherson 2001). These trials also demonstrate va-

riety in the clinical setting from which subjects are recruited and

the inclusion and exclusion criteria used. Overall, trials reported

on one or two clinical outcomes only, and data on adverse effects,

acceptability of the intervention and quality of life measures were

scarce.

A U T H O R S ’ C O N C L U S I O N S

Implications for practice

There is insufficient evidence to determine the efficacy of acupunc-

ture compared to medication in the treatment of depression, based

upon the methodological quality of these trials. There are insuffi-

cient data to demonstrate whether acupuncture is more effective

than a wait list control, non-specific or sham acupuncture control,

or whether acupuncture plus medication is more effective than

acupuncture plus placebo. Recommendations for practice cannot

be made until further high quality research has been undertaken.

Implications for research

Further randomised controlled trials are required to evaluate the

effectiveness of acupuncture in the treatment of depression. All

future randomised trials must be adequately powered and should

consider other outcome measures as described in this review, in

addition to clinical outcomes. Greater attention should be given

to methodological design including randomisation, blinding of

practitioners (where appropriate), outcome assessors and analysts.

There is also a need to improve the quality and reporting of fu-

ture trials. In particular, attention could be given to reporting or

analysis of the person providing the intervention, their length of

training and length of experience, and the rationale for the style

of acupuncture used.

Future studies may need to consider the use of comparative de-

signs using medication or structured psychotherapies (cognitive

behavioural therapy, psychotherapy, counselling) or standard care,

due to the ethics of administering this intervention to this study

population. Future studies should also give consideration to in-

cluding long-term evaluation of effectiveness and adverse effects

of acupuncture.

A C K N O W L E D G E M E N T S

The reviewers would like to acknowledge the CCDAN team for

the assistance with the preparation of the review, including the

Trials Search Coordinator for assistance in developing the search

strategy, the editors, co-editors and other staff within the team and

the Chinese Cochrane Centre for their assistance with searching

databases for trials published in the Chinese literature. To Michael

Arnold for his contribution with the protocol development.



R E F E R E N C E S

References to studies included in this review

Allen 1998 {published data only}∗ Allen JB, Schnyer RN, Hitt SK. The efficiacy of acupuncture in

the treatment of major depression in women. Psychological Science

1998;9(5):397–401.

Han 2002 {published data only}∗ Han C, Li XW, Luo HC. Comparative study of electro-acupuncture

and maprotiline in treating depression. Combined Chinese/WesternJournal 2002;22(7):512–4.

Luo 1985 {published data only}

Luo HC, Yunkui J, Zhan L. Electro-acupuncture versus amitriptyline

in the treatment of depressive states. Journal of Traditional Chinese

Medicine 1985;5(1):3–8.

Luo 1988 {published data only}∗ Luo HC, Shen YC, Jia YK, Zhou D. Clinical study of electro-

acupuncture on 133 patients with depression in comparison with

tricyclic amitriptyline. Chinese Journal of Modern Developments in

Traditional Medicine 1988;8(2):77–80.

Luo 1998 {published data only}

Luo H, Meng F, Jia Y, Zhao X. Clinical research on the therapeutic

effect of the electro-acupuncture treatment in patients with depres-

sion. Psychiatry and Clinical Neurosciences 1998;52:338–40.

Roschke 2000 {published data only}∗ Roschke J, Wolf C, Muller MJ, Wagner P, Mann K, Grozinger M,

et al.The benefit from whole body acupuncture in major depression.

Journal of Affective Disorders 2000;57:73–81..

Xiujuan 1994 {published data only}∗ Xiujuan Y. Clinical observation on needling extrachannel points in

treating mental depression. Journal of Traditional Chinese Medicine1994;14(1):14–8.

References to studies excluded from this review

Agelink 2003 {published data only}∗ Agelink MW, Sanner D, Elch H, Pach J, Bertling R, Lemmer W,

et al.Does acupuncture influence cardiac autonomic nervous system

in patients with minor depression or anxiety disorders. Fortschritteder Neurologie und Psychiatrie 2003;71:141–9.

Chang-du 1994 {published data only}∗ Chang-du L, Yong H, Ying-kun L, Ka-ming H, Zhen-ya J. Treat-

ing post stroke depression with “mind refreshing antidepressive”:

acupuncture therapy: a clinical study of 21 cases. International Jour-nal of Clinical Acupuncture 1994;5(4):389–93.

References to ongoing studies

Allen {published data only (unpublished sought but not used)}

Acupuncture in the treatment of depression. Ongoing study Set

1997.

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C H A R A C T E R I S T I C S O F S T U D I E S

Characteristics of included studies [ordered by study ID]

Allen 1998

Methods Single blind randomised controlled trial (it remains possible that the acupuncture therapists developed

some awareness between the treatments). Randomisation was computer generated and was undertaken

centrally . The patient, therapist and outcome assessor were blind. It was unclear if the analyst was blind.

Four women dropped out (13%). An intention to treat analysis was performed.

Participants Thirty eight women aged 18 to 45 were recruited in the United States. Inclusion criteria were major

depression as described by DSM IV. Exclusion criteria: dysthymia or chronic depression, history of

psychosis or mania, substance abuse, current treatment, endocrine abnormalities, history of central nervous

system lesions or any medical condition causing depression, pregnancy, suicide potential.

Interventions Women were randomly allocated to acupuncture, non specific acupuncture and a wait list control for

eight weeks. The non specific acupuncture and wait list control then received acupuncture. The eight

week intervention involved two sessions a week for the first four weeks, followed by one session a week

thereafter.

Outcomes Subjects completed the Hamilton Rating Scale for Depression (HRSD), and Beck Depression Inventory

at baseline, 8 and 16 weeks.

Notes A power calculation was not reported.

Risk of bias

Item Authors’ judgement Description

Allocation concealment? Yes A - Adequate

Han 2002

Methods Acupuncture versus standard medication. No details could be obtained from the author on how the

allocation sequence was generated and the method of concealment. The study participant and therapist

were not blind and it was unclear if the outcome assessor, and analyst were blind to the study group.

Participants Sixty six men and women aged 18-55 years were recruited to the trial from the Beijing University mental

health institute, China. Inclusion criteria were ICD 10 and a score of greater than 20 on the Hamilton

Depression Scale. Exclusion criteria were not specified.

Interventions Subjects were randomly allocated to receive electro-acupuncture or maprotiline. Electro-acupuncture

was administered for 45 minutes, six times a week over six weeks. The medicated group received daily

medication with doses ranging from 75-250 mg, for six weeks.



Han 2002 (Continued)

Outcomes Subjects completed the Hamilton depression rating scale, self rating scale for depression, clinical global

impression scale and Ashberg rating scale for side effects. Outcome measurements were collated at baseline,

14, 28 and 24 days from trial entry.

Notes A power calculation was not reported. Complete follow up was obtained. Intention to treat analysis was

performed.

Risk of bias


Allocation concealment? Unclear B - Unclear

Luo 1985

Methods Electro acupuncture versus amitriptyline. No details were provided on randomisation and blinding. There

was no loss to follow up reported and an intention to treat analysis was performed.

Participants Forty seven men and women were recruited to the trial. Subjects scored 20 or more on the Hamilton

Rating Scale. No exclusion criteria were specified.

Interventions Two acupuncture points were stimulated Baihui and Yintang. Needles were stimulated using electro

acupuncture. Subjects received 6 sessions a week for 5 weeks. Subjects taking their medication received

an initial dose of 25mg 3 times a day for one week. The treatment dose was then increased to an average

dose of 142mg.

Outcomes The Hamilton Rating scale, Clinical Global Impression Chart, and the Rating scale for side effects

(ASBERG) were interviewed by two psychiatrists at the beginning and end of the trial.

Notes A power calculation was not performed. There were no losses to follow up. An intention to treat analysis

was performed.

Risk of bias





Luo 1988

Methods Electro acupuncture versus amitriptyline. No details were provided on randomisation. No details were

reported on blinding. There was no loss to follow up reported and an intention to treat analysis was

performed.

Participants Two hundred and forty one men and women were recruited from 3 psychiatric hospitals in China. Subjects

scored 20 or more on the Hamilton Rating Scale. No exclusion criteria were specified. Subjects were aged

32-64 years.


acupuncture. Subjects received 6 sessions a week for 6 weeks. Subjects taking their medication received an

initial dose of 25mg 3 times a day for one week. The treatment dose was then increased to 50 mg three

times a day.


(ASBERG) were completed at the start and end of the trial.


was performed.

Risk of bias



Luo 1998

Methods Electro acupuncture versus amitriptyline versus electro acupuncture and amitriptyline. No details were

provided on randomisation. Outcome assessors were blind to the study group, no other details were

provided. There was no loss to follow up reported and an intention to treat analysis was performed.

Participants Twenty nine men and women were recruited to the trial. Subjects were recruited from a closed ward at

the Beijing Medical University Hospital. All participants were drug free for the week before commencing

the trial. Subjects scored 20 or more on the Hamilton Rating Scale. No exclusion criteria were specified.

Mean age was 36 years and the mean course of depression was 7.9 years.


acupuncture for 45 minutes, the current was 3-5mA at a frequency of 2Hz. Subjects received 6 sessions a

week for 6 weeks. Subjects taking their medication received an average dose of 161 mg per day.


(ASBERG).


was performed.



Luo 1998 (Continued)

Risk of bias



Roschke 2000

Methods Single blind placebo controlled trial. No details could be obtained from the author on how the allocation

sequence was generated and the method of concealment. The study participant and therapist were not

blind and it was unclear if the analyst was blind. The outcome assess ors were blind. No data was provided

to verify if subjects were blind to being allocated to acupuncture or placebo acupuncture.

Participants Seventy inpatients aged 20-70 years, in Germany were randomised to the trial. Patients were eligible if

diagnosed with clinical depression equating to DSM IV and a score of greater than 18 on the Hamilton

depression scale. Patients were excluded if suicidal, a diagnosis of schizophrenia or bipolar affective disorders

, or delusions. Patients with coagulation disease, wound healing disease, emphysematous thorax, abnormal

blood cell count, serious liver and kidney disease and epilepsy were excluded. Subjects were aged 20-70

years.

Interventions Subjects were randomised to three study groups. Mianserin (90-120 mg/day, Mianserin (90-120 mg/day)

plus verum acupuncture, Mianserin (90-120 mg/day) plus placebo acupuncture). Up to 20 mg/day

diazepam was allowed if required. Acupuncture was applied three times a week over four weeks.

Outcomes The Global assessment scale, Melancholia scale, Clinical global impressions scale were used to assess

depression. Mean dosage of medication was collected and a self report of improvement.


was performed.

Risk of bias





Xiujuan 1994

Methods Single blind randomised controlled trial of acupuncture compared with standard treatment amitriptyline.

It was unclear as to how the allocation sequence was generated and if there was adequate concealment

of the allocation sequence. Subjects and the therapist were not blind and it was unclear if the outcome

assessor and analyst were blind to study group allocation.

Participants Forty one men and women with clinical depression and the Hamilton Depression scale were recruited to

the trial from in and out patient clinics at the Beijing Medical university, China. No exclusion criteria

were reported.

Interventions Subjects were randomised to receive acupuncture or standard medical care using amitriptyline. Acupunc-

ture points Governor Vessel 24, 20, 14, 12, Conception Vessel 17, 14, Gall Bladder 20, Pericardium 6.

Additional acupuncture points were used depending on the Chinese medical diagnosis. For stagnation

of Liver qi Stomach 23, Spleen 6 and Liver 3 were used. For stagnation of liver blood Colon 4, Liver

3, Spleen 10 were used. For spleen and heart deficiency Heart 7, Pericardium 7, Spleen 6 and Stomach

36 were used. For Spleen and Kidney yang deficiency Kidney 3, Spleen 6, Stomach 36 and Conception

vessel 4 were used. Needles were inserted bi laterally and stimulated manually except for Governor Vessel

24 and 20 which were stimulated using electro acupuncture (frequency 80-100/second). Treatment was

administered for 6 days over 6 weeks. The control group tool 25 mg of amitriptyline on the first day,

the dose was increased by 25-50 mg each day up to 150 mg. In the second week the dose was adjusted

according to response and side effects but ranged from 150 mg to 300 mg daily.

Outcomes The Hamilton Rating Scale for Depression was used to collect data once a week over 6 weeks. Data was

also available on patients cured.

Notes Follow up was complete. There was no power assessment, intention to treat analysis was not mentioned

but was performed.

Risk of bias



Characteristics of excluded studies [ordered by study ID]

Agelink 2003 In this trial of depression and anxiety , no clinically meaningful data were reported. Data were reported on cardio-

vascular outcomes.

Chang-du 1994 In this trial of trial of acupuncture, subjects had experienced a stroke. The inclusion criteria specified by DSM IV

specifies exclusions of symptoms that are clearly due to a medical condition.



Characteristics of ongoing studies [ordered by study ID]

Allen

Trial name or title Acupuncture in the treatment of depression

Methods

Participants 150 men and women meeting the criteria for major depression

Interventions Participants will be randomised to acupuncture or a wait list control

Outcomes Efficacy and safety of acupuncture, with a 18 month follow up on clinical outcomes

Starting date Set 1997

Contact information [email protected]

Notes



D A T A A N D A N A L Y S E S

Comparison 1. Acupuncture versus medication

Outcome or subgroup titleNo. of

studies

No. of

participants Statistical method Effect size

1 Reduction in severity of

depression

5 409 Mean Difference (IV, Random, 95% CI) 0.53 [-1.42, 2.47]

1.1 Electro-acupuncture 3 307 Mean Difference (IV, Random, 95% CI) -0.36 [-3.19, 2.46]

1.2 Classical acupuncture

trials


2 Improvement in depression 4 375 Risk Ratio (M-H, Random, 95% CI) 1.20 [0.94, 1.51]

Comparison 2. Acupuncture versus wait list control


studies

No. of



depression

1 23 Mean Difference (IV, Random, 95% CI) -5.6 [-13.25, 2.05]


Comparison 3. Acupuncture versus non-specific acupuncture


studies

No. of



depression

1 23 Mean Difference (IV, Random, 95% CI) -8.80 [-15.03, -2.57]


Comparison 4. Acupuncture plus medication versus medication


studies

No. of



depression

1 21 Mean Difference (IV, Random, 95% CI) 3.10 [1.04, 5.16]




Comparison 5. Acupuncture plus medication versus acupuncture plus placebo


studies

No. of



depression



Analysis 1.1. Comparison 1 Acupuncture versus medication, Outcome 1 Reduction in severity of depression.

Review: Acupuncture for depression

Comparison: 1 Acupuncture versus medication

Outcome: 1 Reduction in severity of depression

Study or subgroup Treatment Control Mean Difference Weight Mean Difference

N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Electro-acupuncture

Luo 1985 27 12.8 (10.5) 20 14.2 (8.3) 10.3 % -1.40 [ -6.78, 3.98 ]

Luo 1988 133 8.3 (8.07) 108 10.4 (11.4) 26.3 % -2.10 [ -4.65, 0.45 ]

Luo 1998 8 11.6 (2.54) 11 9.9 (2.3) 29.5 % 1.70 [ -0.52, 3.92 ]

Subtotal (95% CI) 168 139 66.2 % -0.36 [ -3.19, 2.46 ]

Heterogeneity: Tau2 = 3.63; Chi2 = 5.10, df = 2 (P = 0.08); I2 =61%

Test for overall effect: Z = 0.25 (P = 0.80)

2 Classical acupuncture trials

Han 2002 30 11.73 (6.13) 31 9.89 (6) 22.1 % 1.84 [ -1.21, 4.89 ]

Xiujuan 1994 20 15.5 (6.74) 21 12.8 (9.27) 11.7 % 2.70 [ -2.24, 7.64 ]

Subtotal (95% CI) 50 52 33.8 % 2.08 [ -0.52, 4.67 ]

Heterogeneity: Tau2 = 0.0; Chi2 = 0.08, df = 1 (P = 0.77); I2 =0.0%


Total (95% CI) 218 191 100.0 % 0.53 [ -1.42, 2.47 ]



-10 -5 0 5 10

Favours treatment Favours control








1 Electro-acupuncture

Luo 1985 27 12.8 (10.5) 20 14.2 (8.3) 10.3 % -1.40 [ -6.78, 3.98 ]

Luo 1988 133 8.3 (8.07) 108 10.4 (11.4) 26.3 % -2.10 [ -4.65, 0.45 ]

Luo 1998 8 11.6 (2.54) 11 9.9 (2.3) 29.5 % 1.70 [ -0.52, 3.92 ]

Subtotal (95% CI) 168 139 66.2 % -0.36 [ -3.19, 2.46 ]



-10 -5 0 5 10







2 Classical acupuncture trials

Han 2002 30 11.73 (6.13) 31 9.89 (6) 22.1 % 1.84 [ -1.21, 4.89 ]

Xiujuan 1994 20 15.5 (6.74) 21 12.8 (9.27) 11.7 % 2.70 [ -2.24, 7.64 ]

Subtotal (95% CI) 50 52 33.8 % 2.08 [ -0.52, 4.67 ]



-10 -5 0 5 10




Analysis 1.2. Comparison 1 Acupuncture versus medication, Outcome 2 Improvement in depression.



Outcome: 2 Improvement in depression

Study or subgroup Treatment Control Risk Ratio Weight Risk Ratio

n/N n/N M-H,Random,95% CI M-H,Random,95% CI

Luo 1985 12/27 6/20 8.9 % 1.48 [ 0.67, 3.27 ]

Luo 1988 72/133 50/108 84.5 % 1.17 [ 0.90, 1.51 ]

Roschke 2000 5/20 6/21 5.4 % 0.88 [ 0.32, 2.42 ]

Xiujuan 1994 4/22 1/24 1.2 % 4.36 [ 0.53, 36.12 ]

Total (95% CI) 202 173 100.0 % 1.20 [ 0.94, 1.51 ]

Total events: 93 (Treatment), 63 (Control)



0.1 0.2 0.5 1.0 2.0 5.0 10.0

Favours control Favours treatment

Analysis 2.1. Comparison 2 Acupuncture versus wait list control, Outcome 1 Reduction in severity of

depression.


Comparison: 2 Acupuncture versus wait list control




Allen 1998 12 -11.7 (7.3) 11 -6.1 (10.9) 100.0 % -5.60 [ -13.25, 2.05 ]

Total (95% CI) 12 11 100.0 % -5.60 [ -13.25, 2.05 ]

Heterogeneity: not applicable


-10 -5 0 5 10




Analysis 2.2. Comparison 2 Acupuncture versus wait list control, Outcome 2 Improvement in depression.


Comparison: 2 Acupuncture versus wait list control




Allen 1998 5/12 2/11 100.0 % 2.29 [ 0.55, 9.49 ]

Total (95% CI) 12 11 100.0 % 2.29 [ 0.55, 9.49 ]




0.1 0.2 0.5 1.0 2.0 5.0 10.0


Analysis 3.1. Comparison 3 Acupuncture versus non-specific acupuncture, Outcome 1 Reduction in severity

of depression.


Comparison: 3 Acupuncture versus non-specific acupuncture




Allen 1998 12 -11.7 (7.3) 11 -2.9 (7.9) 100.0 % -8.80 [ -15.03, -2.57 ]

Total (95% CI) 12 11 100.0 % -8.80 [ -15.03, -2.57 ]



-10 -5 0 5 10




Analysis 3.2. Comparison 3 Acupuncture versus non-specific acupuncture, Outcome 2 Improvement in

depression.


Comparison: 3 Acupuncture versus non-specific acupuncture




Allen 1998 5/12 1/11 100.0 % 4.58 [ 0.63, 33.36 ]

Total (95% CI) 12 11 100.0 % 4.58 [ 0.63, 33.36 ]




0.1 0.2 0.5 1.0 2.0 5.0 10.0


Analysis 4.1. Comparison 4 Acupuncture plus medication versus medication, Outcome 1 Reduction in

severity of depression.


Comparison: 4 Acupuncture plus medication versus medication




Luo 1998 10 13 (2.5) 11 9.9 (2.3) 100.0 % 3.10 [ 1.04, 5.16 ]

Total (95% CI) 10 11 100.0 % 3.10 [ 1.04, 5.16 ]



-10 -5 0 5 10




Analysis 4.2. Comparison 4 Acupuncture plus medication versus medication, Outcome 2 Improvement in

depression.


Comparison: 4 Acupuncture plus medication versus medication




Roschke 2000 4/22 1/24 100.0 % 4.36 [ 0.53, 36.12 ]

Total (95% CI) 22 24 100.0 % 4.36 [ 0.53, 36.12 ]




0.1 0.2 0.5 1.0 2.0 5.0 10.0


Analysis 5.1. Comparison 5 Acupuncture plus medication versus acupuncture plus placebo, Outcome 1

Reduction in severity of depression.


Comparison: 5 Acupuncture plus medication versus acupuncture plus placebo




Luo 1998 10 13 (2.5) 8 11.6 (2.5) 100.0 % 1.40 [ -0.92, 3.72 ]

Total (95% CI) 10 8 100.0 % 1.40 [ -0.92, 3.72 ]



-10 -5 0 5 10




Analysis 5.2. Comparison 5 Acupuncture plus medication versus acupuncture plus placebo, Outcome 2

Improvement in depression.


Comparison: 5 Acupuncture plus medication versus acupuncture plus placebo




Roschke 2000 4/22 8/24 100.0 % 0.55 [ 0.19, 1.56 ]

Total (95% CI) 22 24 100.0 % 0.55 [ 0.19, 1.56 ]




0.1 0.2 0.5 1.0 2.0 5.0 10.0


W H A T ’ S N E W

Last assessed as up-to-date: 16 March 2004.

31 October 2008 Amended Converted to new review format.

H I S T O R Y

Protocol first published: Issue 1, 2003

Review first published: Issue 2, 2005

17 March 2004 New citation required and conclusions have changed Substantive amendment

C O N T R I B U T I O N S O F A U T H O R S

Caroline Smith conceptualised and took the lead in writing the protocol and review, performed initial searches of databases for trials,

was involved in selecting trials for inclusion, performed data extraction and quality assessment of the included trials, was responsible

for statistical analysis and interpretation of the data.

Phillipa Hay was involved with selecting trials for inclusion, performed data extraction and quality assessment of the included trials,

interpretation of the data and commented on drafts of the protocol and review.



D E C L A R A T I O N S O F I N T E R E S T

None

S O U R C E S O F S U P P O R T

Internal sources

• The University of South Australia, James Cook University, Australia.

External sources

• No sources of support supplied

I N D E X T E R M S

Medical Subject Headings (MeSH)

∗Acupuncture Therapy; Depression [∗therapy]; Randomized Controlled Trials as Topic

MeSH check words

Female; Humans; Male



Documents

Acupuncture for Depression